Cagayan State University

COLLEGE OF MEDICINE
Carig Campus, Tuguegarao City

SURGERY WARD

Submitted by:
Medicine3-A Group 1
Agbugay, Rishi Jamivie
Aguisanda, Estephanie
Andrews, Doll Suzanne

Preceptor:
Dr. Jhorell Cadang

GENERAL DATA
Name: M.C.
Age: 34 years old
Gender: Female
Marital Status: Married
Address: Quirino, Isabela
Birthdate: May 5, 1985
Birthplace: Quirino, Isabela
Religion: Roman Catholic
Occupation: Part-time Cook in a Cafeteria
Nationality: Filipino

Date of Admission: February 12, 2020

Date of Interview: February 17, 2020
Time of History Taking: 3:15 pm
Informant: Patient
Reliability: 95%

CHIEF COMPLAINT
RUQ pain

HISTORY OF PRESENT ILLNESS

 6 days PTA, the patient experienced sudden onset of RUQ pain that radiates on her back with a pain
severity of 7/10. She was constipated and with loss of appetite but no headache, fever, and vomiting were
noted. The patient seek medical consultation in Yumena Hospital in Roxas, Isabela and she had
undergone diagnostic procedures and her Ultrasound showed presence of 2 stones approximately 7 and
8mm in her gallbladder, and was admitted.
 2 days PTA, after 4 days of admission in Yumena Hospital, she was given medications such as Ursodiol,
Cefpodoxime and Rowachol and was sent home
 1 day PTA, patient still had loss of appetite and felt that she was not getting better and so she decided to
seek medical consultation in CVMC hence admission.
PAST MEDICAL HISTORY
 CHILDHOOD ILLNESS: The patient had no known childhood illness
Immunizations: Patient cannot remember the vaccinations given
 ADULT ILLNESS:
 Medical: Breast Cancer (2014); had undergone chemotherapy of 2/6 sessions (November-December 2014);

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  Surgical: Mastectomy on her Right Breast (2014)

FAMILY HISTORY

 Patient claimed that there is no family history of hypertension, diabetes, asthma, heart disease, and cancer. Her
husband and 4 children have no known illnesses as well.

PERSONAL AND SOCIAL HISTORY

• The patient is 34 years old and was married to her husband (37 y/o) for almost 9 years. They had 4 children. She
is a part-time cook in a cafeteria.
• She denied using any prohibited drugs at all.
• She does not smoke nor drinks alcohol.

REVIEW OF SYSTEMS

Constitutional: (+) weight loss, (+) general body weakness, No fatigue, fever, nor chills
Integumentary: no unusual change in color, (-) rashes, (-) itchiness or scaling
HEENT
Head: No headache, dizziness, nor light-headedness.
Eyes: No eye pain, lacrimation nor redness seen
Ears: No earaches, discharge, tinnitus, vertigo, impaired hearing, and itching
Nose: No epistaxis, congestion, discharge, itchiness
Mouth & Throat: No swelling, gum bleeding, or sore throat
Respiratory: (-) dyspnea, (-) cough, (-) sputum production, nor hemoptysis
Cardiovascular: (-) chest pain, (-) palpitations, (-) easy fatigability (-) orthopnea.
Gastrointestinal: (+) Abdominal pain, (+) loss of appetite, (+) nausea, (+) constipation, (+) Abdominal distention, (-)
vomiting, (-) change in bowel habit, (-) diarrhea
Genitourinary: No polyuria, dysuria, hematuria, urinary urgency, oliguria, nocturia, (+) incontinence
Hematologic: No pallor, easy bruising, hematoma, nor prolonged bleeding
Musculoskeletal: no muscle weakness, varicose veins and muscle pain in lower extremities
Neurologic: No memory loss, nervousness, seizures, numbness, tingling, speech problem, nor sensorial changes
Psychiatric: No nervousness, anxiety, depression, hallucinations or any psychiatric disorders

PHYSICAL EXAM

General Patient is awake, coherent, not in cardiopulmonary distress and is

oriented to time and place
Vital signs Temperature: 35.4ᴼC (Left axillary)
Blood Pressure: 100/60 (Left arm in supine position)
Respiratory Rate: 18 breaths per cycle
Pulse Rate: 86 beats per minute
O2 Sat%: 99%
Skin (-) pallor
(-) cyanosis
(-) jaundice
Head, Eyes, Ears, Nose, Throat Head: Normocephalic, No head fracture
Eyes: Non-icteric sclerae, Pale palpebral conjunctiva, Pupils are
equal and round, reactive to light and accommodation
Ears: No discharges and pain
Nose: Mucosa is pink, septum is in the midline
Throat & Mouth: Mucosa is pink, uvula is in midline, no pain
Neck No palpable lymph nodes or mumps
No carotid bruits

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 Breast (+) Scar on her Right Breast, Not symmetrical, (-) discharges,
(-) inversion or retraction on (L) nipple, (-) dimpling, (-) palpable
mass, (-) axillary lymphadenopathy
Thorax and Lungs Thorax is symmetric, no chest retractions, (-) tachypnea
Heart Adynamic precordium
PMI at 5th ICS MCL
Regular rate and rhythm
(-) Murmur
Abdomen (+) Abdominal Tenderness, Decreased Bowel Sounds, (-)
palpable mass,
Extremities (+) paraplegia

Salient Features:

34 year old female presenting with

RUQ pain that radiates to the back
Nausea
Loss of appetite
Abdominal tenderness

Initial Impression:

Chronic Cholecystitis and Metastatic Breast Cancer

Differential Diagnosis:

Acute Calculous Cholecystitis – inflammation of the gallbladder due to obstruction of cystic duct
Rule in Rule out
RUQ pain (-) fever
Nausea (-) anorexia
Abdominal tenderness (-) vomiting
(-) murphy’s sign
(-) unremitting RUQ pain

Choledecholithiasis – common bile duct stone

Rule in Rule out
RUQ pain (-) Jaundice
Nausea (-)vomitting

Biliary Pancreatitis - Obstruction of the pancreatic duct by an impacted stone or temporary obstruction by a stone
passing through the ampulla
Rule in Rule out
RUQ pain (-)fever
Nausea (-)jaundice

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